Oregon pharmacy error reporting program still not working after three years

View full sizeThe Associated PressOregon druggists are not participating in a program designed to reduce pharmacy errors.

A nearly three-year-old effort to improve patient safety by reducing
pharmacy errors has failed because Oregon's druggists have declined to
participate.

Opening in the fall of 2008 after years of preparation, an adverse-event reporting system set up by the Oregon Patient Safety Commission was
supposed to generate a flood of confidential messages that would help
officials and pharmacists improve the safety of customers.

Instead, just six reports have been submitted in the life of the program.

In contrast, the Oregon Board of Pharmacy receives about 600 complaints a
year. And the hundreds of pharmacy board complaints likely represent a
tiny fraction of the dispensing errors made by Oregon pharmacies,
according to Mike Millard, assistant professor at the Pacific University
School of Pharmacy.

Studies indicate a 3-percent prescription error rate, translating to
"tens of thousands" of likely druggist mistakes in Oregon each year, he
says.

Officials say many pharmacists fear fines and don't report errors to the
pharmacy board. The Oregon Patient Safety Commission was set up to be a
confidential safe harbor to report problems in the entire health care
system. It's a voluntary program; pharmacists don't have to participate.

But while nursing homes and hospitals have used the system, pharmacists
have not. The commission has released several reports highlighting
issues in the state's health care system, but not about Oregon's roughly
800 retail pharmacies. That's because the number of reports was not
enough to draw conclusions.

"I think its fair to say that the pharmacy piece has not worked," says
Jim Dameron, the commission's recently retired former administrator.
Because he oversaw the system, "in part the failure was mine. I hope
they have the chance to take another run at it but it's a tough one."

"We're already being regulated by a state agency," he says. "So the
additional participation in the Patient Safety Commission is just
another reporting mechanism that is external to what we already do."

Bethany Higgins, who took over as the commission's administrator in
January, hopes to revive the system using a more intuitive online report
instead of lengthy fax questionnaires. She defends pharmacists, saying
"They're doing the best they can with that retail environment."

No other state has a pharmacy reporting system, says Jill Rosenthal of
the National Academy for State Health Policy. In Oregon, most pharmacy
chains did not sign up. Chain pharmacies say their safety programs are
sufficient.

"Safety is a top priority," says Ashley Flower, a Rite-Aid spokeswoman.

Crook, the BiMart director of pharmacy, called his safeguards "more than adequate."

State pharmacy board officials say their yearly inspections suggest that
safety procedures are rarely consulted at some retail pharmacies. A
recent newsletter catalogued several dispensing errors that occurred
last year, including:

A pharmacy customer was pulled over by police for driving erratically
after being mistakenly sold a sedative rather than the prescription a
doctor had written.

Another customer took the wrong pill for a week thinking it was his blood pressure prescription.

Gary Schnabel, director of the pharmacy board, thinks mandatory
reporting would improve pharmacy reporting rates. Dameron, the former
safety commission administrator, thinks the state should instead mount a
high-visibility campaign to pressure pharmacy chains to participate.

"What I would love to see is have them take it on one more time and in a
very public way," he says. "Let the whole world watch to see what the
response is."